Differences in intraoperative and surgical outcomes between normotensive pheochromocytomas and sympathetic paragangliomas (PPGLs) and hypertensive PPGLs: results from the PHEO-RISK STUDY.

PURPOSE: To compare the intraoperative and surgical outcomes of normotensive pheochromocytomas and sympathetic paragangliomas (PPGLs), hypertensive PPGLs and non-PPGL adrenal lesions. METHODS: This a retrospective multicenter cohort study of patients with PPGLs from 18 tertiary hospitals. A control group of histologically confirmed adrenocortical adenomas (non-PPGL group) was selected to compare intraoperative and surgical outcomes with of the normotensive PPGLs. RESULTS: Two hundred and ninety-six surgeries performed in 289 patients with PPGLs were included. Before surgery, 209 patients were classified as hypertensive PPGLs (70.6%) and 87 as normotensive PPGLs. A higher proportion of normotensive PPGLs than hypertensive PPGLs did not receive alpha presurgical blockade (P = 0.009). When we only considered those patients who received presurgical alpha blockers (200 hypertensive PPGLs and 76 normotensive PPGLs), hypertensive PPGLs had a threefold higher risk of intraoperative hypertensive crisis (OR 3.0 [95% 1.3-7.0]) and of hypotensive episodes (OR 2.9 [95% CI 1.2-6.7]) than normotensive PPGLs. When we compared normotensive PPGLs (n = 76) and non-PPGLs (n = 58), normotensive PPGLs had a fivefold higher risk of intraoperative complications (OR 5.3 [95% CI 1.9-14.9]) and a six times higher risk of postoperative complications (OR 6.1 [95% CI 1.7-21.6]) than non-PPGLs. CONCLUSION: Although the risk of intraoperative hypertensive and hypotensive episodes in normotensive PPGLs is significantly lower than in hypertensive PPGLs, normotensive PPGLs have a greater risk of intraoperative and postoperative complications than non-PPGL adrenal lesions. Therefore, it is recommended to follow the standard of care for presurgical and anesthetic management of PPGLs also in normotensive PPGLs.

Prevalence, risk factors and evolution of diabetes mellitus after treatment in primary aldosteronism. Results from the SPAIN-ALDO registry.

PURPOSE: To evaluate the prevalence, risk factors and evolution of diabetes mellitus (DM) after targeted treatment in patients with primary aldosteronism (PA). METHODS: A retrospective multicenter study of PA patients in follow-up at 27 Spanish tertiary hospitals (SPAIN-ALDO Register). RESULTS: Overall, 646 patients with PA were included. At diagnosis, 21.2% (n = 137) had DM and 67% of them had HbA1c levels < 7%. In multivariate analysis, family history of DM (OR 4.00 [1.68-9.53]), the coexistence of dyslipidemia (OR 3.57 [1.51-8.43]) and advanced age (OR 1.04 per year of increase [1.00-1.09]) were identified as independent predictive factors of DM. Diabetic patients were on beta blockers (46.7% (n = 64) vs. 27.5% (n = 140), P < 0.001) and diuretics (51.1% (n = 70) vs. 33.2% (n = 169), p < 0.001) more frequently than non-diabetics. After a median follow-up of 22 months [IQR 7.5-63.0], 6.9% of patients developed DM, with no difference between those undergoing adrenalectomy and those treated medically (HR 1.07 [0.49-2.36], p = 0.866). There was also no significant difference in the evolution of glycemic control between DM patients who underwent surgery and those medically treated (p > 0.05). CONCLUSION: DM affects about one quarter of patients with PA and the risk factors for its development are common to those of the general population. Medical and surgical treatment provides similar benefit in glycemic control in patients with PA and DM.

Retrospective interobserver agreement on diagnoses of 4th and 5th carpometacarpal fracture-dislocation and hamate fracture in plain X-ray - Is CT essential after ulnar carpometacarpal pain?

OBJECTIVE: To determine interobserver agreement and reliability of different radiological parameters in the assessment of fracture-dislocation of the 4th and 5th carpometacarpal joints (FD CMC 4-5) and associated hamate fracture on radiographs. MATERIALS AND METHODS: A retrospective, consecutive case series of 53 patients diagnosed with FD CMC 4-5. Emergency room diagnostic radiology images were reviewed by four independent observers. The reviews included assessment of radiological patterns and parameters in relation to CMC fracture-dislocations and associated injuries previously described in the literature, to analyze their diagnostic power (specificity and sensitivity) and reproducibility (interobserver reliability). RESULTS: Among 53 patients, mean age 35.3 years, dislocation of the 5th CMC joint was present in 32/53 (60%) of patients, mostly (11/32 [34%]) associated with 4th CMC dislocation and base of 4th and 5th metacarpal fracture. The most common presentation of hamate fracture, in 4/18 (22%), was associated with combined 4th and 5th CMC dislocation and base of metacarpal fracture. Computed tomography (CT) was performed in 23 patients. Performing CT scan was significantly associated with hamate fracture diagnosis (p < 0.001). Interobserver agreement was slight (0-0.641) for most of the parameters and diagnoses. Sensitivity ranged from 0 to 0.61. Overall, the described parameters had low sensitivity. CONCLUSION: Radiological parameters described for assessment of fracture-dislocation of the 4th and 5th CMC joints and associated hamate fracture have a slight interobserver agreement index in plain X-ray and low sensitivity for diagnostic assessment. These results suggest the need for emergency medicine diagnostic protocols that include CT scan for such injuries. GOV IDENTIFIER: NCT04668794.

Phase diagram of the NaCl-water system from computer simulations.

NaCl aqueous solutions are ubiquitous. They can crystallize into ice, NaCl, or NaCl · 2H2O depending on the temperature-concentration conditions. These crystallization transitions have important implications in geology, cryopreservation, or atmospheric science. Computer simulations can help understand the crystallization of these solids, which requires a detailed knowledge of the equilibrium phase diagram. We use molecular simulations in which we put at contact the solution with the solid of interest to determine points of the solid-solution coexistence lines. We follow two different approaches, one in which we narrow down the melting temperature for a given concentration and the other in which we equilibrate the concentration for a given temperature, obtaining consistent results. The phase diagram thus calculated for the selected model (TIP4P/2005 for water molecules and Joung-Cheatham for the ions) correctly predicts coexistence between the solution and ice. We were only able to determine NaCl · 2H2O-solution coexistence points at higher temperatures and concentrations than in the experiment, so we could not establish a direct comparison in this case. On the other hand, the model underestimates the concentration of the solution in equilibrium with the NaCl solid. Our results, alongside other literature evidence, seem to indicate that ion-ion interactions are too strong in the model. Our work is a good starting point for the improvement of the potential model and for the study of the nucleation kinetics of the solid phases involved in the phase diagram.

Homogeneous nucleation of NaCl in supersaturated solutions.

The seeding method is an approximate approach to investigate nucleation that combines molecular dynamics simulations with classical nucleation theory. Recently, this technique has been successfully implemented in a broad range of nucleation studies. However, its accuracy is subject to the arbitrary choice of the order parameter threshold used to distinguish liquid-like from solid-like molecules. We revisit here the crystallization of NaCl from a supersaturated brine solution and show that consistency between seeding and rigorous methods, like Forward Flux Sampling (from previous work) or spontaneous crystallization (from this work), is achieved by following a mislabelling criterion to select such threshold (i.e. equaling the fraction of the mislabelled particles in the bulk parent and nucleating phases). This work supports the use of seeding to obtain fast and reasonably accurate nucleation rate estimates and the mislabelling criterion as one giving the relevant cluster size for classical nucleation theory in crystallization studies.

The silent variants of pituitary tumors: demographic, radiological and molecular characteristics.

INTRODUCTION: Tumors of the anterior pituitary gland (PTs) are mostly benign tumors with a low prevalence, which has nevertheless increased with advances in brain radiology techniques. Nearly half of PTs are not associated with a clinical endocrine syndrome. These tumors have been indistinctly named non-functioning pituitary adenomas (NFPAs) or silent pituitary tumors (SPTs) and the mechanisms of silencing are not fully known. AIM: To study the frequency and characterize the silent variant of PTs in a large local series, and to assess their pituitary adenohypophyseal gene expression. METHODS: This observational, cross-sectional study was performed in a Pituitary Tumor Center of Excellence and involved 268 PTs. After identifying the different subtypes according to the immunohistochemical (IHC) expression of adenohypophyseal hormones, we studied their gene expression by RT-qPCR. RESULTS: We found that silent tumors were larger and more invasive, but not more proliferative than their functional counterparts. The RT-qPCR complements the IHC typification of PTs, reducing the proportion of null-cell subtype. Finally, some silent PT subtype variants showed lower specific adenohypophyseal hormone gene expression than their functional counterparts, which may contribute to the absence of endocrine manifestations. CONCLUSIONS: This paper highlights the importance of identifying the silent variant of the PTs subtypes. As expected, silent tumors were larger and more invasive than their functioning counterparts. However, there was no difference in the proliferation activity between them. Finally, the lower specific gene expression in the silent than in the functioning counterparts of some PTs subtypes gives insights into the silencing mechanisms of PTs.

Is Somatostatin Receptor and Dopamine Receptor profiling useful in the management of silent somatotroph tumors?

Silent somatotroph tumors (sSTs) are pituitary neuroendocrine tumors (PitNETs) which do not give rise to the clinical syndrome of acromegaly. Differently to their functioning counterparts, the adjuvant medical treatment with somatostatin analogues (SSAs) or dopamine receptors agonists (DAs) has been scarcely addressed in these tumors. As preliminary results of an ongoing research on silencing mechanisms involved in the pathogenesis of sSTs, we have characterized by qRT-PCR the expression of SSTRs and DRDs in a large series of 18 silent and 68 functioning STs. Although the expression of SSTR2 and SSTR5 was lower in sSTs than in functioning ones, we found a negative correlation between SSTR2 and the tumor size of the sSTs. Additionally, levels of expression of DRD2 were similar between the two subtypes suggesting a possible basis for the treatment of these tumors with SSAs and DAs.

Hantavirus pulmonary syndrome in a highly endemic area of Brazil.

Hantavirus pulmonary syndrome (HPS) is the most frequently reported fatal rodent-borne disease in Brazil, with the majority of cases occurring in Santa Catarina. We analysed the clinical, laboratory and epidemiological data of the 251 confirmed cases of HPS in Santa Catarina in 1999-2011. The number of cases ranged from 10 to 47 per year, with the highest incidences in 2004-2006. Gastrointestinal tract manifestations were found in >60% of the cases, potentially confounding diagnosis and leading to inappropriate therapy. Dyspnoea, acute respiratory failure, renal failure, increased serum creatinine and urea levels, increased haematocrits and the presence of pulmonary interstitial infiltrate were significantly more common in HPS patients who died. In addition, we demonstrated that the six cases from the midwest region of the state were associated with Juquitiba virus genotype. The case-fatality rate in this region, 19·2%, was lower than that recorded for other mesoregions. In the multivariate analysis increase of serum creatinine and urea was associated with death by HPS. Our findings help elucidate the epidemiology of HPS in Brazil, where mast seeding of bamboo can trigger rodent population eruptions and subsequent human HPS outbreaks. We also emphasize the need for molecular confirmation of the hantavirus genotype of human cases for a better understanding of the mortality-related factors associated with HPS cases in Brazil.

Influence of electronic apex locators and a gutta-percha heating device on implanted cardiac devices: an in vivo study.

AIM: To evaluate the potential for electromagnetic interference (EMI) of electronic apex locators (EALs) and a gutta-percha heating device (HD) in patients with implantable cardiac pacemakers (ICPs) or cardioverter-defibrillators (ICDs). METHODOLOGY: Two types of EALs (Romiapex A-15 and Novapex) and a HD (Touch'n Heat) were tested in patients followed in an outpatient clinic for cardiac arrhythmias. The heart rhythm was monitored on a computer screen during all experimental phases. After baseline data collection, the patient held each appliance (turned on) for 30 s, simulating their clinical use. If background noise was detected on the cardiac monitor, the sensitivity of the ICP/ICD was lowered by the cardiologist to evaluate the intensity of the detected EMI. RESULTS: Twelve patients were evaluated (5 female and 7 male), and in nine instances, background noise in their cardiac devices related to the use of the endodontic devices was detected (6 patients). After lowering the sensitivity of the cardiac implants, three patients had more severe EMI in six instances, including pauses in ICP function. The presence of a symptomatic or asymptomatic pause was related to the patient's underlying heart rhythm. The HD device produced background noise more often compared to EALs. These were associated with more severe types of EMI. CONCLUSION: The EALs and gutta-percha HD were capable of causing background noise detection or pauses in cardiac implants in vivo. The use of electronic dental devices nearby patients with cardiac implants should be carefully considered in clinical practice.

Statistical transmutation in doped quantum dimer models.

We prove a "statistical transmutation" symmetry of doped quantum dimer models on the square, triangular, and kagome lattices: the energy spectrum is invariant under a simultaneous change of statistics (i.e., bosonic into fermionic or vice versa) of the holes and of the signs of all the dimer resonance loops. This exact transformation enables us to define the duality equivalence between doped quantum dimer Hamiltonians and provides the analytic framework to analyze dynamical statistical transmutations. We investigate numerically the doping of the triangular quantum dimer model with special focus on the topological Z(2) dimer liquid. Doping leads to four (instead of two for the square lattice) inequivalent families of Hamiltonians. Competition between phase separation, superfluidity, supersolidity, and fermionic phases is investigated in the four families.

A jaboticaba extract prevents prostatic damage associated with aging and high-fat diet intake.

Aging and overweight are involved in prostatic lesion development, due to their association with cell proliferation, hormonal imbalance and angiogenesis. The jaboticaba fruit is rich in bioactive compounds, showing potential chemopreventive action such as the capacity to modulate hormones and angiogenesis hallmarks. This study aimed to evaluate the jaboticaba extract (PJE) effect on the prostate morphology and on molecules related to hormone signaling and angiogenesis, during aging and/or high-fat diet (HFD) intake. Seventy FVB mice were distributed into experimental groups: YG group (young: 3 month old mice), AG group (aged: 11 month old mice), HfAG group (aged + HFD), JAGI group (aged + 2.9 g kg-1 PJE), JAGII group (aged + 5.8 g kg-1 PJE), HfJAGI group (aged + HFD + 2.9 g kg-1 PJE) and HfJAGII group (aged + HFD + 5.8 g kg-1 PJE). The ventral prostate was collected for morphological, immunohistochemistry and western-blotting analysis after 60 days of treatment. All PJE treatments promoted hormonal signaling balance and inhibited angiogenesis in the prostates of aged or HFD-fed aged mice, leading to the maintenance of healthy prostate morphology. A high dose of the PJE (JAGII and HfJAGII groups) led to the best capacity to reduce AR (58.40% and 74.42%; p = 0.0240 and p = 0.0023), ERα (30.29% and 45.12%; p = 0.0004 and p < 0.0001), aromatase (39.54% and 55.94%; p = 0.0038 and p = 0.0020), and VEGF (50.81% and 67.68%; p < 0.0001) and increase endostatin immunoexpression. Moreover, HFD intake intensified the hormonal and angiogenic alterations in the aged mouse prostates, contributing to the increase in premalignant lesion incidence. The PJE exerted a dose-dependent positive effect on aged or HFD-fed aged mouse prostates, contributing to the gland microenvironment recovery, mainly due to the hormonal and angiogenic balance. Therefore, we suggest that the PJE can be a potential candidate for prostatic lesion prevention.

Safety of isotretinoin treatment as measured by liver parameters.

Isotretinoin is an analogue of vitamin A and by suppressing the sebaceous glands it is often prescribed in cases of severe acne treatment. The treatment for the average patient is carried out during two to ten months. This study was designed to investigate liver structure, hepatic enzyme levels and the stress oxidative parameter after isotretinoin treatment during a similar period and using the dosages of 1 mg/kg and another one of 10 mg/kg in young male Wistar rats. We have analyzed the blood serum biochemical levels to determine hepatic function and lipid peroxidation, hepatic tissue levels of hepatic enzymes, histology and ultrastructure. The groups receiving 1 mg/kg were not altered after treatment. Their ultrastructure showed a metabolically more active organ after treatment with 10 mg/kg, in which there was an increase in the area occupied by mitochondria and rough reticulum in electron transmission images. The group that received 10 mg/kg also showed increased alkaline phosphatase, decreased high density lipoprotein and low density lipoprotein. The changes observed with the 10 mg/kg dose were not conclusive for liver damage, because of the lack of histological structural modifications and the few biochemical alterations. The 1 mg/kg dose showed a liver responding to some stimuli but without profound alterations. So, we confirm that the proposed protocol with 1mg/kg or 10 mg/kg isotretinoin did not cause important biochemical and histological disfunctions for male Wistar rat livers.

Identification of Zika virus in immature phases of Aedes aegypti and Aedes albopictus: a surveillance strategy for outbreak anticipation.

A progressive increase in the circulation of arboviruses in tropical countries has been observed, accounting for 700,000 yearly deaths in the world. The main objective of this article was to identify the presence of Zika (ZIKV), dengue (DENV), and Chikungunya (CHIKV) viruses in immature stages of Aedes aegypti and Ae. albopictus. Household collections of immature phases of the vectors were carried out in the years 2015 and 2016. A total of 2902 dwellings were visited and the rate of infestation with larvae and pupae of Aedes mosquitoes was 283/1462 (19.4%) in March 2015 and 55/1440 (3.8%) in June 2015. In March 2015, 907 larvae/pupae were collected (583 or 64.3% of Ae. aegypti and 324 or 35.7% of Ae. albopictus) while in June 2015 there was a reduction in the number of immature forms found: 197 larvae/pupae (121 or 61.4% of Ae. aegypti and 76 or 38.6% of Ae. albopictus). This reduction was accompanied by a decrease in suspected human ZIKV cases from March to June 2015. The RT-qPCR performed in 18 pools identified that three (two of Ae. aegypti and one of Ae. albopictus) were positive for ZIKV, and none were positive for DENV or CHIKV. Our findings demonstrated that ZIKV was present in immature stages of insect vectors in the study region at least five months prior to the peak of ZIKV associated cases. Xenomonitoring of immature phases of the vectors may prove useful for predicting outbreaks.

Accuracy of quick sequential organ failure assessment score to predict mortality in hospitalized patients with suspected infection in an HIV/AIDS reference centre in Rio de Janeiro, Brazil.

OBJECTIVES: To compare the discriminatory capacity of the quick sequential organ failure assessment (qSOFA) vs. the systemic inflammatory response syndrome (SIRS) score for predicting 30-day mortality and intensive care unit (ICU) admission in patients with suspicion of infection at an HIV reference centre. METHODS: We performed a prospective cohort study including consecutive adult patients who had suspected infection and who were subsequently admitted to the medical ward. Variables related to qSOFA and SIRS were measured at admission. The performance (area under the receiver operating curve, AUROC) of qSOFA (score ≥2) and SIRS (≥2 criteria) as a predictor of 30-day mortality and ICU admission was evaluated. RESULTS: One hundred seventy-three patients (mean ± standard deviation age, 42.6 ± 12.4 years) were included in the analysis; 107 (61.8%) were male, and 111 (64.2%) were HIV positive. Respiratory and gastrointestinal infections occurred in 49 (28.3%) and 23 (13.3%), respectively. The 30-day mortality rate was 9 (5.2%) of 173. The prognostic performance of qSOFA was similar compared to SIRS, with an AUROC of 0.68 (95% confidence interval, 0.55-0.81) and 0.69 (95% confidence interval, 0.53-0.86) (p 0.96). Twenty patients (11%) were admitted to the ICU; qSOFA and SIRS had a similar discriminatory capacity for ICU admission (AUROC 0.63 (95% confidence interval, 0.51-0.75) and 0.63 (95% confidence interval, 0.50-0.76)), respectively). CONCLUSIONS: We found a poor prognostic accuracy of the qSOFA to predict 30-day mortality in hospitalized patients suspected of infection in a setting with a high burden of HIV infection.

[Attachment process between an infant and his/her mother: the first year]. / Développement du processus d'attachement entre un bébé et sa mère.

Attachment theory is focused upon the development of the attachment process organized jointly by the child and the environmental factors which contribute to the development of the feeling of security. The authors focus on the mother-baby relationships and describe the normative process of attachment relationships during the first year of life. The ethologic perspective of this development is also summarized. The steps of the developing attachment relationship are described. The description of motherhood is focused on the bonding process, which is a more immediate and biologically based process and on caregiving which is a symmetrical motivational system as complex as the attachment one. The main factors known as having an impact on the two processes are described.

Risk factors for early onset prosthetic valve endocarditis: a case-control study.

BACKGROUND: Early onset prosthetic valve endocarditis (EO-PVE) is an infrequent complication of cardiac valve surgery. It is considered a healthcare-associated infection due to contamination of the prosthesis during the implant or in the early postoperative period. AIM: To evaluate which factors may be related to the acquisition of EO-PVE. METHODS: A nested case-control study was conducted from 2006 to 2016. Cases were patients who had definite prosthetic endocarditis by the modified Duke criteria up to 12 months of heart valve replacement. Cases and controls were matched by age, gender, date and type of surgery. FINDINGS: There were 26 cases and 78 controls, in 2496 valve surgeries. The median incidence of EO-PVE was 1.1%. Risk factors identified during surgery were: use of ≥2 cryoprecipitate units (odds ratio (OR): 5.95; 95% confidence interval (CI): 1.31-27.0) and ≥2 plasma units (OR: 2.73; 95% CI: 1.0-7.5). In the postoperative period, associated factors were bloodstream infection (OR: 14.00; CI: 1.49-131.77), pneumonia (4.38; 1.21-15.84), any infection (4.46; 1.63-12.21), central line for ≥2 weeks (5.33; 2.06-13.78), presence of dialysis catheter (3.22; 1.15-9.03), and new open chest surgery (3.89; 1.28-11.78). Mortality at 12 months was 34.6% in cases and 6.4% in controls (OR: 7.73; CI: 2.3-26.06). CONCLUSION: Cases had more infections, invasive procedures and surgical re-interventions in the early postoperative period, which favoured contamination of the newly implanted prosthesis. A preventive approach, with reinforcement of infection control practices, may curb the incidence of this condition.

Bartonella native valve endocarditis: the first Brazilian case alive and well.

Bartonella is an important cause of blood culture-negative endocarditis in recent studies. Seroprevalence studies in the States of Minas Gerais and Rio de Janeiro have shown Bartonella IgG positivity around 14% in healthy adults and 40% in HIV seropositive adults, respectively. A case report of a 46-year-old white male with moderate aortic regurgitation (AR) due to rheumatic heart disease (RHD), admitted due to worsening heart failure, is presented. Clinical features were apyrexia, anemia, polyclonal hypergammaglobulinemia, hematuria and splenomegaly. He was submitted to surgery due to worsening AR. Histopathology of the excised valve showed active bacterial endocarditis and underlying RHD. Routine blood cultures were negative. Indirect immunofluorescence (IFI) assays for Coxiella burnetii were non-reactive. Bartonella henselae IgG titer was 1:4096 prior to antibiotics and 1:512 14 months after treatment. History of close contact with a young cat during the months preceding his admission was elicited.

The anatomy and vascularity of the lunate: considerations applied to Kienböck's disease.

PURPOSE: The purpose of this study was to assess the anatomy and vascularity of the lunate. The genesis of lunatomalacia requires some combination of vascular risk and mechanical predisposition. The findings will be correlated with the major existing theories of the cause of Kienböck's disease. METHODS: We studied 27 cadaver upper limbs using latex injection and the Spalteholz technique. We investigated the blood supply to the lunate. In 24 wrists we evaluated the incidence and distribution of anatomic features, arthrosis, and soft tissue lesions. We correlated the lunate morphology and ligaments disruptions with the arthritic changes. RESULTS: The lunate morphology results as classified by Antuña-Zapico were five type I (20.8%), 18 type II (75%) and one type III (4.2%). The lunate was found to have a separate facet for the hamate in 11 cases (45.8%). The most common size of the facet was found to be 3 mm (range, 3-6 mm). Arthrosis was identified with most frequency in the radius (88.2%) and lunate (94.1%). The triangular fibrocartilage complex was found torn in 58.3%, the lunotriquetral interosseous ligament was torn in 20.8% and the scapholunate interosseous ligament (SLIL) was torn in 54.2% of the wrists. There was a correlation between the presence of arthrosis at the hamate and the presence of a lunate facet (P=0.027) and a correlation between the presence of a tear in the SLIL and arthrosis in the scaphoid (P=0.002). The nutrient vessels entered the lunate through the dorsal and volar poles in all the specimens. The dorsal intercarpal and radiocarpal arches supply blood to the lunate from a plexus of vessels located directly over the lunate's dorsal pole. Vessels entered the dorsal aspect of the lunate through one to three foramina. One to five nutrient vessels were observed entering the volar pole through various ligament insertions, including the ligament of Testut-Kuentz (radio-scapho-lunate (RSL) ligament) and the radiolunate triquetrum ligament (or dorsoradial carpal ligament) and ulnar lunate triquetral ligament. CONCLUSIONS: The lunate had consistent dorsal and palmar arteries entering the bone in all the specimens. The blood supply and foramina number is greater in the volar pole of the lunate than the dorsal pole. The lunate blood supply comes from different ligaments. In the etiopathogeny of Kienböck's disease it is possible that an acute or chronic, traumatic or non-traumatic injury of the vessel bearing ligaments, particularly because of their structure and the location of the RSL ligament, may have an important role in the appearance of lunate necrosis.